complaint·August 9, 2024

On the allegation that due to lack of supervision resident sustained injuries; it is the concern of the reporting party (RP) that Resident #1 (R1) was falling a lot due to possible lack of supervision and during their last fall R1 obtained a hematoma to their face and abrasions to their nose. Record review revealed that R1 was admitted to the facility on 09/21/2022. R1’s physician’s report dated 12/07/2023 indicated that R1 has a diagnosis of dementia, gait instability, and a fall risk. Incident report reviewed revealed that R1 sustained a fall on 12/18/2023, resulting in R1 being transported to the hospital. According to incident report, and staff interviews, R1 was walking to their room with a caregiver watching nearby, and R1 lost their balance as they were entering their room and fell forward onto the floor before the caregiver could prevent their fall. Caregiver immediately went to R1 and called out for the administrator for help. The administrator contacted 911 to have R1 evaluated and taken to the hospital to ensure R1 had no injuries caused by the falls. A second fall occurred on 11/14/2023 resulting in R1 being transported to the hospital. According to the incident report, R1 was in the dining room prior to lunch being served enjoying the background music and decided to get up and try to dance. R1 lost their balance and fell forward, staff immediately rushed to R1’s aid and called EMS to transport for an evaluation. A third fall occured on 05/03/2023, resulting in R1 hitting their head and being transported to the hospital. According to the incident report, R1 was sitting in a chair in the dining room, staff asked R1 if they would like to move to their normal spot for lunch, and as staff made their way to assist R1, R1 stood up from their chair, went to take a step and lost their balance. R1 stumbled forward a few steps and hit their head on the cabinet under the coffee makers. Staff immediately assessed R1, and called 911. Record review and interviews revealed that R1 did not require 1:1 supervision, nor did R1 require an escort when ambulating inside the facility. Incident reports and staff interviews revealed that staff were nearby when all three falls occurred, and that staff followed the proper protocol for obtaining additional medical care and reporting the incidents. Administrator stated that there was nothing that staff could have done to prevent R1's falls. In addition, Interview with R1's family members revealed that they have no concern regarding the care R1 is receiving at the facility, and stated R1 moved too quickly and was not steady. Therefore, based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred; the allegation that “due to lack of supervision resident sustained injuries” is deemed UNSUBSTANTIATED at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued to the Administrator.